Strategies to Eliminate Maladaptive Oral Habits

Common behaviors seen in children and adults with jaw deficits and subsequent speech and feeding disorders are that of maladaptive oral habits. Such habits include jaw clenching and teeth grinding (bruxism), excessive mouthing of objects, thumb and
finger sucking, tongue sucking, lip chewing, nail biting, and extended bottle and pacifier use.1

When these habits are excessive or continue past appropriate developmental necessity, they can lead to poor dental health, be socially stigmatizing, and inhibit the development of speech clarity.

These habits are activities that stimulate the temporomandibular joint (TMJ), a site of sensory organization and stimulation.2

When treating children with speech and language delays and disorders, speech-language pathologists often are faced with questions about oral habits and issues such as drooling and mouthing. Typical suggestions for remediation of undesirable oral habits are behavioral. However, these habits may occur due to physiological reasons.

There are three common reasons that oral habits occur: environmental or external stress, dental misalignment (malocclusions) and physical tension located in the TMJ, and weakness due to instability and underuse of the oral musculature.

Environmental stress is normal and processed differently in each person. Some feel tension in their shoulders or stomach or get frequent headaches, while others may exhibit tension in the oral musculature and TMJ. Maladaptive oral behaviors can be signs of associated stress or tension.1 While normal, adaptive behaviors can promote stability, they can become excessive in those who have associated misuse or lack of use of the jaw and TMJ.

Maladaptive oral habits can be related to the dental structures. When the upper and lower teeth do not meet functionally, there may be a tendency to stimulate the jaw and dentition to improve alignment of the jaw and TMJ and to add sensory stimulation.2 Orthodontia is the prescribed treatment for malocclusions.

Individuals with weakness due to instability and underuse of the oral musculature may exhibit oral habits to stimulate the TMJ and organize and stabilize the body. There may be another reason that they seem to need more stimulation as well. These individuals may evidence low tone and reduced strength in the jaw muscles as a result of lack of use of the oral musculature, or they may have difficulty with appropriate movements due to hypotonicity. Prolonged thumb or finger-sucking, continued reliance on bottle-feeding, and refusal to give up a pacifier may be additional behaviors noted in this population.

The primary goals of speech-language pathology are to satisfy the need for stimulation to the TMJ and increase jaw stability. As stability increases, sensory awareness increases. Therefore, as the muscles of the jaw are used more appropriately, the need to engage in oral habits will decrease. Over a period of time, the habit can be eliminated by following five sequential steps.

The first step is to determine why the individual is demonstrating the observed habit. TMJ stimulation creates calmness and body awareness. Requiring children to stop the behavior or preventing them from engaging in the behaviors may eliminate the behavior temporarily but does not address the need for stimulation and the persistence of the habit.

The second step is to identify why the habit should be eliminated. Does it impact negatively on health, nutritional intake, speech production or dentition? If so, it will be necessary to collect information to explain and validate a recommendation to the family, teachers or other support team members who will help to eliminate the habit.

The third step is to empathize with clients and begin a program plan. Perhaps the only time individuals are content is when the/they are involved in the oral habit. Before beginning therapy, speech-language pathologists should develop a plan that will supply alternative and adequate sensory stimulation to the TMJ and oral structures. Utilize therapy techniques that satisfy the need for TMJ stimulation, do not impact negatively on speech production, and are socially acceptable.

A combination of sensory input with vibration, feeding intervention strategies and oral-motor activities have been the most effective means of improving jaw stability and eliminating the reliance on oral habits for calming. Among the feeding and oral-motor techniques available are chewing (e.g., chewing solids on the back molars, chewing on a variety of therapy tools) and oral-motor activities (e.g., gum chewing program, graduated bite blocks and jaw exercisers).3

Once therapy goals have been identified, the fourth step is to arrange a conference with the child's family, teachers and other support team members. The therapist can present the reasons why the individual may be relying on the habit, the reasons why the habit should be eliminated, and therapy strategies to replace the desired stimuli. It is important to listen to caregiver concerns and affirm that the habit will not be eliminated right away. It will take time to replace and finally eliminate the behavior(s).

The final step is to replace the behaviors. Once the program plan is initiated and the child is receiving adequate stimulation to the TMJ, the habit can be extinguished. Do not eliminate the habit until a substitute is in place. For example, if a child is still drinking from a bottle at age 3 and is unable to receive adequate liquid nutrition from a cup or straw, eliminating the bottle-feeding habit would compromise the child's nutritional integrity. Teach the child to drink therapeutically from a cup or straw before making any attempt to eliminate the bottle.

Sara Rosenfeld-Johnson is the founder of TalkTools® Therapies/ITI. She can be contacted atoromotorsp@aol.com. Jennifer Gray is on staff at Aspen Editing & Consulting Inc. She can be contacted atjennifer@aspenediting.com.

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